Has your organization qualified as a non-profit, tax deductible entity under the US internal revenue code 501(c)(3)?

Yes
No

If NOT, enter application date

Employer Identification Number (E.I.N)

REQUEST

Total Amount Requested

Is this amount for one Fiscal Year?

Yes
No

If NO, for what period?

Use of funds: Please outline proposed project or program. Identifying both your target population and your planned method of improving that group's quality of life. Be specific. Please attach a detailed budget for the use of the requested funds.(1000 characters max - includes spaces)

3. If combined cost of administration, public relations, and fund raising exceeds 20% of total expenditures for the previous fiscal year, please enclose a statement explaining your high administrative expenses

Yes, it does exceed 20% (I have included an explanation)

No, it does not exceed 20%

4. List of corporate donors ($200 or more)

Sent by

Received by AFCC

to be completed by AFCC

5. Project or program budget

Sent by

Received by AFCC

to be completed by AFCC

I certify that the aforementioned and enclosed information is complete and accurate.

Name (person to contact if we have questions)

Title

Date

Home Telephone number
(Mandatory - this number will be kept private and only be used in case of an emergency)